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Test-and-Treat Strategy for Dyspepsia Is Supported

Am Fam Physician. 2002 Aug 15;66(4):660.

Although dyspepsia affects up to 40 percent of the general population and, in Canada, accounts for about 7 percent of visits to family physicians, the etiology is never established in about 60 percent of cases. Chiba and colleagues studied the effectiveness of the test-and-treat strategy, in which patients testing positive for Helicobacter pylori by the urea breath test are treated with eradication therapy.

The test-and-treat study recruited 294 adult patients from 36 family practices in Canada. The patients had uninvestigated epigastric discomfort for at least three months, excluding those with only heartburn, regurgitation, or both. Patients also were excluded if they had previously undergone investigation of dyspepsia or eradication therapy for H. pylori infection. The patients were randomly assigned to receive omeprazole in a dosage of 20 mg, metronidazole in a dosage of 500 mg, clarithromycin in a dosage of 250 mg, or omeprazole plus two placebos twice daily for seven days. Following treatment, patients were followed monthly for one year. A seven-point scale was used to assess symptoms each month. Quality of life assessments and measures of health care costs were monitored. The breath test was repeated at three and 12 months.

The groups were well matched in all important variables. Based on intention to treat, 50 percent of the 145 patients assigned to eradication therapy were successful compared with 36 percent of the 149 patients receiving placebos plus omeprazole. The estimated number needed to treat was seven. Eradication was documented in 75 percent of the 145 patients assigned to eradication therapy, and these patients had higher success rates than those with persistent infection (54 percent compared with 39 percent). Quality of life significantly improved in three of the five domains monitored for patients on eradication therapy. Adverse events were reported by 42 percent of patients in each treatment group.

The authors conclude that the test-and-treat strategy results in significant symptomatic improvement for at least one year in primary care patients with dyspepsia. In a related study of 586 patients followed for one year, McColl and colleagues demonstrated that the noninvasive urea breath test was as effective as endoscopy for investigating primary care patients with dyspepsia.